Form PERS-60 (back)
APPLICANTS AFFIDAVIT OF DISABILITY
Physicians consulted since onset of disability:
Date of first treatment:
If hospitalized for disabling disease/illness/injury give names of hospitals:
Date your current term ends:
Last election in which you were a candidate for office:
Did you lose?
THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.
NOTE: Any person who knowingly files an Affidavit/Statement of Claim containing
any false or misleading information is subject to criminal and civil penalties
Sworn to and subscribed before me this
Notary Public Applicant’s Name (please print or type)